Cardiovascular Surgery

Vol.9(2), Apr 2001

In this issue

Cardiovasc Surg 2001 Apr;9(2):201-203 A case of coronary artery fistula draining into the pericardium causing hematoma. Mutlu H, Serdar Kucukoglu M, Ozhan H, Kansyz E, Ozturk S, Uner S. A 28-yr old female patient admitted to our clinic because of dyspnea and chest pain. Her transesophageal echocardiography demonstrated a huge mass on the anterolateral wall of the left ventricle causing dysfunction of the myocardium. Coronary angiography demonstrated left anterior descending artery fistula draining into the pericardial cystic mass. Hydatic cyst was suspected and ELISA and hemagglutinin tests were both negative for Echinococcus granulosus. Magnetic resonance image of the heart showed a mass thought to be a hematoma inside the cyst. She underwent surgery. The cystic lesion with a pure hematoma inside, was excised, and the fistula between left anterior descending artery and the mass was ligated without any complications. To our knowledge, this is the first case of a pericardial hematoma due to a coronary artery fistula, in the English literature.

Cardiovasc Surg 2001 Apr;9(2):194-200 Immunohistochemical and ultrastructural evidence that dendritic cells infiltrate stenotic aortocoronary saphenous vein bypass grafts. Cherian SM, Bobryshev YV, Liang H, Inder SJ, Wang AY, Lord RS, Tran D, Pandey P, Halasz P, Farnsworth AE. We earlier speculated that antigen-presenting dendritic cells may be involved in the immune reactions leading to saphenous vein bypass graft failure. The purpose of this study was to confirm whether dendritic cells are present in stenotic human saphenous vein bypass grafts. Segments of stenotic saphenous vein grafts were explanted from 14 patients at re-do bypass operation and ten normal saphenous veins were harvested during femoro-popliteal grafting. Sections of specimens were analysed using cell type specific antibodies to identify dendritic cells (CD1a, S-100), T-lymphocytes (CD3), macrophages (CD68), smooth muscle cells (alpha-SMA) and endothelial cells (FVIII). Dual immunostaining, confocal immunofluorescent laser scanning microscopy and electron microscopy were used. Stenotic grafts showed structural alterations of intimal hyperplasia and varying degrees of atherosclerotic degeneration. No cells expressing CD1a and S-100 were observed in the intima and media of normal saphenous veins. Cells expressing these antigens were present around areas of medial neovascularization and within intimal atherosclerotic lesions in saphenous vein bypass grafts. Electron microscopy demonstrated the presence of cells containing a well-developed tubulovesicular system which is unique to cells from the dendritic cell family. Double immunohistochemistry and confocal immunofluorescent microscopy revealed the co-localization of T-lymphocytes with dendritic cells. Dendritic cells are present in stenotic saphenous vein bypass grafts. Dendritic cells may be responsible for antigen presentation and modulation of immune reactions in accelerated graft atherosclerosis through their interaction with T-lymphocytes.

Cardiovasc Surg 2001 Apr;9(2):188-193 Does warm antegrade intermittent blood cardioplegia really protect the heart during coronary surgery? Bical OM, Fromes Y, Paumier D, Gaillard D, Foiret JC, Trivin F. Objective: Intermittent antegrade blood cardioplegia (IABC) has been standardized as a routine technique for myocardial protection in coronary surgery. However, if the myocardium is known to tolerate short periods of ischemia during hypothermic arrest, it may be less tolerant of warm ischemia, so the optimal cardioplegic temperature of intermittent antegrade blood cardioplegia is still controversial. The aim of this study was to compare the effects of warm intermittent antegrade blood cardioplegia and cold intermittent antegrade blood cardioplegia on myocardial pH and different parameters of the myocardial metabolism.Methods: Thirty patients undergoing first-time isolated coronary surgery were randomly allocated into two groups: group 1 (15 patients) received warm (37 degrees C) intermittent antegrade blood cardioplegia and group 2 (15 patients) received cold (4 degrees C) intermittent antegrade blood cardioplegia. The two randomization groups had similar demographic and angiographic characteristics. Total duration of cardiopulmonary bypass (108+/-17 and 98+/-21min) and of aortic cross-clamping (70+/-13 and 65+/-15min) were similar. The cardioplegic solutions were prepared by mixing blood with potassium and infused at a flow rate of 250ml/min for a concentration of 20mEq/l during 2min after each anastomosis or after 15min of ischemia. Intramyocardial pH was continuously measured during cardioplegic arrest by a miniature glass electrode and values were corrected by temperature. Myocardial metabolism was assessed before aortic clamping (pre-XCL), 1min after removal of the clamp (XCL off) and 15min after reperfusion (Rep) by collecting coronary sinus blood samples. All samples were analyzed for lactate, creatine kinase (MB fraction), myoglobin and troponin I. Creatine kinase and troponin I were also daily evaluated in peripheral blood during 6days post-operatively.Results: The clinical outcomes and the haemodynamic parameters between the two groups were identical. In group 1, XCL off and Rep were associated with higher coronary sinus release of lactate (5.5+/-1.8 and 2.2+/-0.5mmol/l) than in group 2 (2.0+/-0.7 and 1.6+/-0.3mmol/l, P<0.05). Mean intramyocardial pH was lower in group 1 (7.23+/-0.08) than in group 2 (7.65+/-0.30, P<0.05). There were no significant differences between the two groups with respect of creatine kinase (MB fraction) either after Rep or during the post-operative period. Lower coronary sinus release of myoglobin was detected at Rep in group 1 (170+/-53?g/l) than in group 2 (240+/-95?g/l, P<0.05). At day 1, a lower release of troponin I was found in group 1 (0.11+/-0.07g/ml) compared to group 2 (0.17+/-0.07ng/ml, P<0.05).Conclusion: With regards to similar clinical and haemodynamic results, myocardial protection induced by warm IAEX is associated with more acidic conditions (intramyocardial pH and lactate release) and less myocardial injury (myoglobin and troponin I release) than cold intermittent antegrade blood cardioplegia during coronary surgery.

Cardiovasc Surg 2001 Apr;9(2):184-7 Autotransfusion decreases blood usage following cardiac surgery - a prospective randomized trial. Dalrymple-Hay MJ, Dawkins S, Pack L, Deakin CD, Sheppard S, Ohri SK, Haw MP, Livesey SA, Monro JL. Introduction: 10% of blood issued by the National Blood Service (220000) is utilised in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We tested the efficacy of autotransfusion of washed postoperative mediastinal fluid in a prospective randomized trial.Patients and methods: 166 patients undergoing coronary artery bypass grafting (CABG), valve or CABG+valve procedures were randomized into three groups. The indication for transfusion was a postoperative haemoglobin (Hb) <10g/l or a packed cell volume (PCV) <30. When applicable, group A patients received washed post-operative drainage fluid. Group B all received blood processed from the cardiopulmonary bypass (CPB) circuit following separation from CPB and if appropriate washed post-operative drainage fluid. Group C were controls. Groups were compared using analysis of variance.Results: There was no significant difference in age, sex, type of operation, CPB time and preoperative Hb and PCV between the groups. Blood requirements were as shown.Twelve patients in group A and 10 in group B did not require a homologous transfusion following processing of the mediastinal drainage fluid.Conclusion: Autotransfusion of washed postoperative mediastinal fluid can decrease the amount of homologous blood transfused following cardiac surgery. There was no demonstrable benefit in processing blood from the CPB circuit as well as mediastinal drainage fluid.

Cardiovasc Surg 2001 Apr;9(2):179-83 Coronary reoperations in patients with a patent internal mammary artery graft. Noyez L, van Eck FM, Skotnicki SH, Brouwer RM. Objective: Analysis of short and long term results, clinical, functional and subjective status of patients, with a patent arterial graft, after coronary reoperation (RECABG).Methods: Perioperative and follow-up data of 71 patients, undergoing coronary reoperations (1987-8) were studied. A cross-sectional follow-up was conducted, functional evaluation by the Duke Activity Status Index (DASI), and patient's evaluation of his life situation were registered.Results: Perioperative mortality was 7%. Eleven patients died during follow-up. The 12-month and 60-month survival was 96% and 80%. Event-free survival was 86% and 51%. Family doctors declared that 55/66 (83%) had benefitted from the coronary reoperations. New York Heart Association decreased significantly from 3.4+/-0.5 preoperative versus 1.5+/-0.4 postoperative. The mean DASI was 38.06+/-10.42. At the moment of the cross-sectional follow-up, 45/55 patients (82%) declared to have benefitted from the coronary reoperations.Conclusion: Improvement in New York Heart Association-class, good postoperative functional capacity, and patients positive evaluation, justify coronary reoperations in patients with a patent internal mammary artery graft.

Cardiovasc Surg 2001 Apr;9(2):177-8 Tension-free left ITA graft - the pericardial strip technique. Nezic D, Peric M, Knezevic A, Cirkovic M, Jovic M, Bojic M. Emphysematous lung occupying the whole dome of the left pleural cavity and expanding well over the midline may occasionally present a significant problem for positioning of the left internal thoracic artery, although the graft has been mobilized up to its origin. To avoid an undue tension on it, we combined a well known technique of the pericardial incision with the pericardial strip technique, enabling the lung to expand freely.

Cardiovasc Surg 2001 Apr;9(2):166-76 Colonisation of prosthetic grafts by immunocompetent cells in a sheep model. Bobryshev YV, Inder SJ, Cherian SM, Lord RS, Ao PY, Hawthorne WJ, Fletcher JP. The present study examined the distribution of immunocompetent cells in synthetic vascular grafts in an experimental sheep model. Sixty-two adult Merino sheep underwent synthetic patch closure of a longitudinal arteriotomy in the left common carotid artery. The synthetic patch materials used were gelatin sealed Dacron (n=10), fluoropassivated Dacron (n=10), Fluoropassiv (n=12), polyurethane (n=10), expanded polytetrafluoroethylene (n=10) and carbon-lined expanded polytetrafluoroethylene (n=10). The sheep were sacrificed after four weeks when the prosthetic patches were harvested and fixed in 10% neutral buffered formalin. Transverse sections were taken along the graft and paraffin embedded. Serial sections were stained with cell type specific antibodies to identify T-lymphocytes (CD3(+)), dendritic cells (S-100(+)), endothelial cells (von Willebrand factor(+)) and smooth muscle cells (smooth muscle alpha-actin(+)). All six graft types contained CD3(+) and S-100(+) cells in the neointima, within the synthetic matrix and in the perigraft layer. Three different tissue responses to synthetic materials were observed and the grafts were classified accordingly into three groups: (1) gelatin sealed Dacron, fluoropassivated Dacron and Fluoropassiv; (2) expanded polytetrafluoroethylene and carbon-lined expanded polytetrafluoroethylene; (3) polyurethane. The three synthetic materials in Group 1 showed almost identical reactions with least accumulation of immunocompetent cells within the synthetic material but greater accumulation of immuno-inflammatory infiltrates in the perigraft vascular tissue. In this group, new vessels penetrated into the synthetic material and there was prominent formation of foreign body (giant) cells. Group 2 showed greater accumulation of immunocompetent cells within the synthetic material itself but only sparse immuno-inflammatory infiltrates in the perigraft tissue. Group 3 showed a high degree of inflammatory response within both the synthetic material and the perigraft vascular tissue. These observations demonstrate that immunocompetent cells colonise the synthetic matrix of grafts and accumulate in the perigraft tissue, but inflammatory responses vary in different graft types.

Cardiovasc Surg 2001 Apr;9(2):161-5 Could prolonged air travel be causally associated with subclavian vein thromboembolism? Teruya TH.

Cardiovasc Surg 2001 Apr;9(2):159-61 Deep vein thrombosis in airline passengers - the incidence of deep vein thrombosis and the efficacy of elastic compression stockings. Scurr JH, Coleridge Smith PD, Machin S.

Cardiovasc Surg 2001 Apr;9(2):158-9 Risk factors for venous thromboembolism following prolonged air travel: a prospective study. Arfvidsson B.

Cardiovasc Surg 2001 Apr;9(2):157-8 Traveller's venous thromboembolism. Parsi KA, McGrath MA, Lord RS.

Cardiovasc Surg 2001 Apr;9(2):150-6 Chicicago views. Caprini JA, Dubow J.

Cardiovasc Surg 2001 Apr;9(2):149-50 Sydney views. Lord RS.

Cardiovasc Surg 2001 Apr;9(2):147-9 Vienna views. Partsch H.

Cardiovasc Surg 2001 Apr;9(2):145-7 Air travel and deep vein thrombosis - the London experience. Burnand KG, Smith A.

Cardiovasc Surg 2001 Apr;9(2):145 Air travel related venous thromboembolism. Hawaii views. Eklof B, Arfvidsson B.

Cardiovasc Surg 2001 Apr;9(2):141-4 Surgical treatment for popliteal artery entrapment syndrome. Ohara N, Miyata T, Oshiro H, Shigematsu H. Purpose: This study was a retrospective review of 11 limbs of 10 patients with popliteal artery entrapment syndrome (PAES) treated surgically in a 20-yr period.Methods: The patients were aged 34.7+/-17.4 SEM yr. Arteriographic findings varied, showing medial deviation in two limbs, poststenotic dilatation in four limbs and occlusion of the popliteal artery in five limbs. In addition, computed tomographic (CT) scanning showed positive findings of PAES in all the limbs.Results: The surgical procedures consisted of musculotendonous section (MTS) with autogenous saphenous vein (ASV) graft in seven limbs, MTS and ASV patch angioplasty with or without thromboendarterectomy in three limbs, and MTS alone in one limb. All the ASV grafts were found to be patent during the postoperative follow-up period (10.9+/-4.0yr).Conclusion: CT scanning was demonstrated to be the most sensitive diagnostic modality for PAES, and MTS with or without ASV grafting method was considered to be the best surgical procedure for PAES.

Cardiovasc Surg 2001 Apr;9(2):133-40 Endovascular stenting of superficial femoral artery stenosis and occlusions: results and risk factor analysis. Cheng SW, W Ting AC, Wong J. Purpose: To determine the early and midterm results of femoro-popliteal angioplasty with adjunctive stenting and to identify factors affecting early and continuing success.Methods: Sixty-nine consecutive balloon angioplasty procedures on the superficial femoral artery (SFA) were performed in 60 limbs and 55 patients in the operating theater. Fifty-two percent of lesions were occlusions, and 87% involved the distal half or the whole segment of the SFA. Immediate endovascular stenting was used in all procedures, involving the placement of 105 stents, with a mean stented length of 13.8cm. Twenty-nine procedures (43%) were performed for critical ischemia. Three-monthly duplex ultrasound was used for follow up assessment, with stenosis of >50% defined as the endpoint for failure. The patient demographic and biochemical data, and procedural details were correlated with success criteria according to Society of Vascular Surgery standards.Results: Initial technical success by intent to treat was 92%, with four procedure-related complications and no deaths. Initial success by anatomic, hemodynamic and clinical criteria were 98.3, 96.7 and 93.3% respectively (92.2, 90.6 and 87.5% by intent to treat). Cumulative primary patency at 6, 12, and 24months was 73.1, 62.6 and 53.8%, and secondary patency 84.9, 72.1 and 72.1% correspondingly. Significant factors relating to inferior patency were occlusions, stented segment length >10cm, procedure in claudicants, and the use of the Memotherm stent.Conclusions: Angioplasty and stenting of the superficial femoral artery has acceptable primary and secondary patency rates even in the presence of long stenosis and occlusions. A duplex surveillance program is recommended for early detection and timely treatment of restenosis.

Cardiovasc Surg 2001 Apr;9(2):127-32 Hemodynamic results of femoral vein valve repair. de Souza GG, Pereira AH, Costa LF, Silva JC, Burihan E. Our aim was to assess the hemodynamic and clinical responses associated with valve repair surgery in 37 patients with severe chronic venous insufficiency. Patients classified as C(4-6)E(P)A(SDP)P(R) (primary venous dysfunction with skin changes with reflux of superficial, deep and perforating veins) were submitted to a novel procedure combining the closed technique described by Kistner with the Dacron sleeve technique described by Hallberg (mean follow-up=24months). A significant improvement in Valsalva test results (P<0.0001), ambulatory pressure (P=0.0099), venous refilling time (P<0.0001), and reflux index (P<0.0001) was observed. Postoperative reactive hyperemia and gradient tests confirmed absence of venous obstruction signs. On their last visit, 85.3% of the patients had no ulceration, and edema was absent or minimal in over 90%. About 70% of the patients referred partial or complete relief of pain in the affected limb. The combined surgical technique was effective to control venous reflux 24months after the procedure. A longer follow-up would be necessary to assess long-term results.

Cardiovasc Surg 2001 Apr;9(2):122-6 Percutaneous transluminal angioplasty in patients with ischemic tissue necrosis is worthwhile. Melliere D, Berrahal D, D'Audiffret A, Desgranges P, Allaire E, Becquemin JP. Purpose: Ischemic tissue necrosis is usually associated with long or sequential arterial obstructions. As a result, the role of percutaneous transluminal angioplasty (PTA), which addresses only short lesions, in patients presenting with trophic changes remains questionable. The purpose of this study was to evaluate the effectiveness of PTA in diabetic and non-diabetic patients presenting with grade 4 Fontaine's classification.Method: Between January 1992 and December 1997, 1352 patients with aorto-iliac and/or infrainguinal occlusive diseases were admitted to our institution. Three hundred and ten patients who presented with distal gangrene (95.5%) or ischemic ulcers (4.5%) were identified. The patients consisted of 117 diabetics and 193 non-diabetics. PTA alone was performed in 26 diabetics (group 1) and in 30 non-diabetics (group 2). Their charts were retrospectively reviewed and the patients were recalled for clinical examination and non-invasive monitoring.Results: Follow-up was available for all patients and ranged from 1 to 4 years. The survival rate was significantly higher in diabetic patients than in non-diabetic patients (96% vs 77% at 1 year; p<0.05 and 91% vs 66% at 3 years; p<0.05). In group 1, the primary cumulative patency rate at 1 and 3 years was 76%. In group 2, the primary cumulative patency rate at 1 and 3 years were 85% and 80%, respectively. Three patients in group 1 required a redo PTA at 4 months, resulting in an assisted primary patency rate at 1 and 3 years of 88%. In contrast, no patients in group 2 required additional PTA. In group 1, the limb salvage rate at 1 and 3 years was 84%; and in group 2, 80% and 75%, respectively.Conclusion: The results of PTA in both groups were encouraging. Dilation of one or two short stenoses, despite multiple distal lesions, may improve distal flow sufficiently to promote wound healing. Thus, this procedure may be recommended in selected patients suffering from ischemic tissue loss. However, during the first 6 months following PTA, diabetic patients should be followed carefully with Duplex as they are prone to early restenosis.

Cardiovasc Surg 2001 Apr;9(2):109-121 Development of atherosclerosis and plaque biology. Kadar A, Glasz T. Atherosclerosis is a leading issue in mortality and morbidity in the civilized world. A number of hypotheses for atherogenesis indicate the complexity of initiation and development of this multifactorial disease. Morphologic types of lesions have long since been studied in order to understand plaque evolution and determinants of plaque complication, a frequent cause of acute ischemic accidents. Chemical and pathophysiological studies defined the wide spectrum of molecular interactions between cellular elements of atherosclerotic lesions. Recently, molecular biologic investigations provide a deeper insight into genetic predispositions for the disease and have widened our understanding of the pathogenic mechanisms. Until we can diminish the high prevalence of the disease, precise information is needed on the evolution of atherosclerosis in order to slow progression, select optimal therapies and prevent plaque complications and their consequences.